1. Healthcare-Associated Infections and Infection Control
Timothy H. Dellit, MD
Medical Director, Infection Control
Harborview Medical Center

2. Patient Safety and Infection Control
Prevention, monitoring, and feedback
Healthcare-associated infections
Catheter-associated bloodstream infections
Ventilator-associated pneumonia
Surgical site infections
Catheter-associated UTI
Transmission of multidrug-resistant/marker organisms
MRSA
VRE
Carbapenem-resistant Acinetobacter
ESBL-producing organisms → MDR Enterobacteriaceae
C. difficile
Aspergillus in burn and immunocompromised populations
Tuberculosis

3. Increasing Regulation and Reporting
CMS RHQDAPU
FY2013-FY2015
CLA-BSI
SSI
CA-UTI
Central line bundle compliance
MRSA bacteremia
C. difficile
Influenza vaccination of HCW
CMS and “preventable events”
FY2008
Catheter-associated urinary tract infection
Vascular catheter-associated infections
Mediastinitis after CABG
FY2009
SSI following select orthopedic procedures
Spinal fusion
Elbow and shoulder arthroplasty
SSI following bariatric surgery
Mandatory reporting of healthcare-associated infections (HB 1106)
Central line infections in ICU: July 2008
Ventilator-associated pneumonia: January 2009
Selected surgical site infections: January 2010
Cardiac surgery
Total hip and knee arthroplasty
Hysterectomy

6. “MDRO Bundle” Hand Hygiene Contact precautions
Minimize shared equipment
Environmental cleaning
Healthcare-associated infections preventive bundles
Catheter-associated BSI
Ventilator-associated pneumonia
Catheter-associated UTI
SCIP measures
Active surveillance cultures
Chlorhexidine baths
Antimicrobial stewardship
Patient and staff education
Lancet 2000;356:

8. Role of Environmental Contamination
Contact Contamination
Percent positive
Percent of Surfaces Positive for MRSA
Infect Control Hosp Epidemiol 1997;18:

9. Who are you sleeping with?
40% increased risk of transmission associated with prior occupant’s MRSA or VRE carriage
Arch Intern Med 2006;166:
Infect Control Hosp Epidemiol 2011;32:201-6

10. To Survey or Not to Survey?
Surveillance Cultures Reduce MRSA Bacteremia
Interventions over 9 yr
Sterile CVC placement
Alcohol-based hand hygiene
Hand hygiene campaign
ICU surveillance for MRSA (16 months)
29% of newly detected MRSA carriers develop infection within 18 months
75%
67%
Incidence density per 1000 pt-days
40%
Reduced ICU transmission by 47%
43 vs. 23 cases per 1000 at risk patients
Clin Infect Dis 2003;36:281-5
Clin Infect Dis 2006;43:971-8

11. VA MRSA Initiative Decreased transmission Reduced HAIs MRSA VAP
MRSA CLA-BSI
C. difficile in non-ICU
VRE in ICU and non-ICU
N Engl J Med 2011;364:

12. Active Surveillance and Contact Precautions in ICU
Cluster randomized study in 18 ICUs
Surveillance cultures for MRSA and VRE
- Mean delay in results 5.2 days
Control
Intervention
MRSA or VRE colonization or infeciton (rate per 1000 pt-days)
35.6
40.4
Days in Contact Precautions (%)
38%
51%
Hand hygiene
59%
69%
Gloves
72%
82%
Gowns
77%
N Engl J Med 2011;364:

13. Daily Chlorhexidine Baths
Baseline
CHG Baths P
MRSA acquisition*
5.04
3.44
0.046
VRE acquisition*
4.35
2.19
0.008
VRE bacteremia*
2.13
0.59
0.0006
*per 1000 pt-days
Crit Care Med 2009;37:

14. Chlorhexidine baths in Trauma ICU
Before and after introduction of daily CHG baths in TICU
In pre-contact precaution era
Reduction in CR-BSI from 8.4 to 2.1 per 1000 catheter-days (P=0.01)
Reduction in MRSA VAP from 5.7 to 1.6 per 1000 vent-days (P=0.03)
Arch Surg 2010;145:

15. HMC Nosocomial MRSA Rates Quarterly
Number of Cases
2007: 331 Cases
2008: 268 Cases
2009: 154 Cases
2010: 142 Cases
0.9 per 1000 pt-days
Source: Infection Control, for more information, please contact Dr. Tim Dellit,
Confidential QI

16. Which of the following bundle elements is NOT correct?
VAP and head of bed > 30 degrees
VAP and sedation awakening
VAP and DVT prophylaxis
Central line and maximum barriers including full body drape, sterile gown, sterile gloves, mask with eye protection, and haircover
Central line and povidone-iodine skin prep
Central line and hand hygiene

17. Central Line-Associated BSI
ICU CVC utilization 0.39 – 0.71 catheters/pt
15 million catheter-days per year in US
ICU rate 1.2 to 5.3 per 1000 catheter-days (NHSN mean)
80,000 CR-BSI annually in US ICUs
Attributable mortality 0-35%
Healthcare cost $296 million to $2.3 billion
Attributable cost $15,000-$56,000
Prolonged ICU and hospital LOS
Clin Infect Dis 2002;35:
National healthcare Safety Network (HNSN) Report, Data Summary for 2009

18. NHSN CLA-BSI Pathogens
Pathogen (%) (%) (%)
Coag-negative staphylococci
Staphylococcus aureus *
Enterococcus
Candida sp
Enterobacter
Pseudomonas aeruginosa
Klebsiella pneumoniae
E. Coli
Clin Infect Dis 2002;35:
Infect Control Hosp Epidemiol 2008;29:
*MRSA 5.6%, MSSA 4.3%

19. Prevention of Catheter-Associated BSI
IHI “Central Line Bundle”
Hand hygiene
Chlorhexidine skin prep
Maximal barriers
Full drape
Mask, hair cover, sterile gown, sterile gloves
Optimal catheter site selection
Daily review of line necessity
Implementation AND documentation
Institute for Healthcare Improvement

20. Median Bloodstream Infections per 1000 Catheter-Days
Bundle in Action
Median Bloodstream Infections per 1000 Catheter-Days
Months After Implementation
Reduction in mean rate from 7.7 to 1.4 per 1000 catheter-days
N Engl J Med 2006;355:

21. UHC Benchmark of Key Performance Measures
Hospital Performance
Patient Level
% of cases
median
range
Central Venous Catheter Placed in the Subclavian Vein
44.2%
14.3 – 73.3%
Evidence of Maximal Barrier Precautions for Insertion
0.0%
0.0 – 8.2%
Hand Washing
0.0 – 39.0%
Full Body Drape
3.0%
0.0 – 46.3%
Sterile Gloves and Gown
1.9%
Cap and Mask
0.0 – 13.6%
Chlorhexidine Skin Prep for Insertion
0.0 – 98.1%
Daily Dressing Inspection
97.5%
25.1 – 100%
Daily Assessment of Medical Necessity to Continue CVC
16.4%
0.0 – 100%
Operational
Yes % (n)
Site #
Best Practice* CVC Insertion Policy
11.8% (2)
29, 89
Mandated Use of a CVC Insertion Checklist
84, 87
UHC’s MVP Bundle of Care Interventions
Infect Control Hosp Epidemiol 2008;29:440-2

22. National Reduction in CLA-BSI
JAMA 2009;301:727-36

23. MRSA Central Line-Associate BSI
50% reduction in MRSA CLA-BSI (0.43 vs 0.21 per 1000 catheter-days)
JAMA 2009;301:727-36

24. Hospital-Acquired UTI
• 40% of healthcare-associated infections
• 80% due to indwelling urethral catheter
Survey of Hospital Monitoring
Potential Strategies
Insertion/care
• Catheter reminders/
automatic stop orders
• Bladder US scanners
• Condom catheters
• Antimicrobial catheters
No monitoring (%)
Clin Infect Dis 2008;46:243-50
Aymptomatic bacteriuria
vs.
Symptomatic UTI in patients without localizing GU symptoms

25. CA-UTI Pathogens NHSN 2006-2007
Infect Control Hosp Epidemiol 2008;29:

26. Catheter-Associated UTI
Duration of catheterization is primary risk
Providers unaware of catheter status
Students 21%
Interns 22%
Residents 27%
Attendings 38%
Daily assessment of need, especially when transferred from ICU to floor
Am J Med 2000;109:476-80

27. Ventilator-Associated Pneumonia
Rate 0.7 – 7.4 per 1000 ventilator days (NHSN 2009)
10-30% of intubated patients
Incidence increases with duration of MV
Day 1-5: 3% risk per day
Day 6-10: 2% risk per day
> 10 days: 1% risk per day
Attributable mortality rate 33-50%
Increased LOS 7-9 days
Cost of $40,000 per patient
Accounts for 50% of ICU antimicrobials
Clinical vs. microbiologic definitions
Poor external quality measure
Am J Respir Crit Care Med 2005;171:

28. NHSN Pooled Mean VAP by Unit 2009 Report
Rate per 1000 vent-days
BICU: Burn PICU: Pediatric med/surg
CICU: Coronary NICU: Neurosurgery
CT ICU: Cardiothoracic SICU: Surgical
MICU: Medical TICU: Trauma
Am J Infect Control 2009;37:

29. “Ventilator Bundle” Head of bed elevation > 30 degrees
Daily “sedation awakening” and assessment of readiness to extubate
Oral care (chlorhexidine)
Peptic ulcer disease prophylaxis
Deep vein thrombosis prophylaxis
*Institute for Healthcare Improvement

30. Late Onset VAP Pathogens
July 03 – June 04 (N=138)
July 08 – June 09 (N=114)
July 09 – June 10 (N=83)
Acinetobacter
44 (32%)
4 (4%) ↓
4 (5%) ↓
MRSA
32 (23%)
8 (7%) ↓
2 (2%) ↓
MSSA
21 (15%)
30 (26%)
23 (28%)
Haemophilus
20 (14%)
24 (21%)
13 (16%)
Pseudomonas
13 (9%)
14 (12%)
15 (18%)
Enterobacter
4 (3%)
12 (11%)
4 (5%)
Klebsiella spp.
7 (5%)
7 (6%)
5 (6%)
Serratia spp.
5 (3%)
1 (1%)
E. coli
6 (4%)
6 (5%)

31. Which of the following has been demonstrated to reduce surgical site infections and is currently part of SCIP recommendations?
Peri-operative prophylactic antibiotics should be given within 60 minutes after incision
Peri-operative prophylactic antibiotics should be given within 60 minutes before incision and discontinued within 24 hours
Peri-operative antibiotics should be continued until the drains are out
Nasal carriage of S. aureus should be eradicated prior to surgery
Pre-surgical bath with chlorhexidine

32. Surgical Care Improvement Project
Implemented by CDC and Centers for Medicare and Medicaid Services in 2002
Nationally included procedures
Cardiothoracic, vascular, colon, hip or knee arthroplasty, vaginal or abdominal hysterectomy
Performance measures (Baseline of 34,133 medicare patients in 2001)
Antimicrobial prophylaxis within 1 hr of incision (55.7%)
Antimicrobial agent c/w current guidelines (92.6%)
Discontinuation within 24 hours after surgery (40.7%)
Also, clipping rather than shaving, normothermia, glucose control, morning beta-blocker, DVT prophylaxis
Role of MRSA screening?
Arch Surg 2005;140:174-82

33. Perioperative Prophylactic Antibiotics Timing of Administration
14/369
15/441
1/41
1/47
Infections (%)
1/81
2/180
5/699
5/1009
Hours From Incision
N Engl J Med 1992;326:281-6

34. Society of Thoracic Surgeons
Rationale
Unique patient risks
Cardiopulmonary bypass, systemic hypothermia
Devastating sequelae of mediastinitis (7-20% mortality)
No randomized studies < 48 hrs in CT surgery
Major Recommendations
Postoperative prophylactic antibiotics are given for 48 hours or less
Duration not dependent on chest tube removal
If risk for MRSA, then vancomycin AND cefazolin
Routine mupirocin administration for all patients in the absence of documented negative testing for staphylococcal colonization
Ann Thorac Surg 2006;81:
Ann Thorac Surg 2006;83:

35. Is Vancomycin Alone Adequate?
Pathogens causing deep SSI following CABG, Hip and Knee Arthroplasty
Acceptable for cardiac, vascular, or orthopedic surgery:
Beta-lactam allergy
Documented rationale
NNIS

36. Meta-analysis of Seven Randomized Studies: Glycopeptide vs
Meta-analysis of Seven Randomized Studies: Glycopeptide vs. β-Lactam for Prevention of Surgical Site Infection after Cardiac Surgery
MSSA more frequent in vancomycin group 3.7% vs. 1.3%
(J Thorac Cardiovasc Surg 2002;123:326-32)
Clin Infect Dis 2004;38:

37. Intranasal Mupirocin and Surgical Site Infections
Nasal carriage of S. aureus and risk of surgical site infection
Orthopedic surgery with prosthetic implants in 272 patients, RR (Infect Control Hosp Epidemiol 2000;21: )
Cardiothoracic surgery in 1980 patients, OR (J Infect Dis 1995;171:216-9)
10/10 pre- and post-surgical pairs identical by phage typing
Randomized, double-blind, placebo-controlled trial of pre-surgical mupirocin in 3864 patients (N Eng J Med 2002;346:1871-7)
No difference in nosocomial infections, nosocomial S. aureus infections, or S. aureus surgical site infections
S. aureus carriers (N=891)
4.5 fold increase in S. aureus SSI
Significant reduction in S. aureus nosocomial infections (4.0 vs. 7.7)
Trend towards decreased S. aureus SSI (3.7 vs. 5.9, 37%, P=0.15)
Same strain in nares and site of infection in 85%

38. Universal Screening of Surgical Patients? JAMA 2008;299:1149-57
Prospective, cross-over study of 21,754 surgical patients
87% on admission
MRSA colonization 5.1%
Standard practices for all patients with MRSA
Contact precautions
Adjustment of pre-op prophylaxis
Intranasal mupirocin and chlorhexidine body wash
No difference in MRSA SSI (0.99 vs per 100)
34% of MRSA carriers did not receive appropriate pre-op prophylaxis
None identified through outpatient screening developed MRSA infection

39. 2% Chlorhexidine and 70% alcohol (Chloraprep) vs
2% Chlorhexidine and 70% alcohol (Chloraprep) vs. 10% Povidone Iodine for Surgical-Site Antisepsis
Randomized, multi-center
849 patients
Clean-contaminated surgery
NNT: 17 patients
N Engl J Med 2010;362:18-26

40. Pre-operative Chlorhexidine Baths
Cochrane Review of six randomized trials with 10,007 patients RR
Chlorhexidine vs. placebo (0.80 to 1.04)
Chlorhexidine vs. bar soap (0.57 to 1.84)
Chlorhexidine vs. no washing (0.17 to 0.79)
Cochrane Database Syst Rev Apr 18;(2):CD Review

41. It’s a small world…
26 y o medical student returns April 20, 2009 from an international elective in Mexico. On April 27 she presents to ED with 4 day h/o fever 39 C, cough, HA, myalgias, and diarrhea. That same day you hear reports of a novel Influenza A virus H1N1 associated with increased mortality in Mexico.

42. Which of the following is MOST correct regarding influenza?
No special precautions are necessary for patients with suspected influenza since it is not very transmissible.
Influenza is primarily transmitted by large droplets (> 5 microns), therefore healthcare workers should use Droplet Precautions with a surgical mask with eye protection for routine care to prevent contamination of mouth, nose, and conjunctiva.
Patients with 2009 H1N1 should be placed in airborne isolation with use of N-95 respirators while patients with H1N1 seasonal influenza should be placed in droplet precautions.
A negative rapid antigen test rules out influenza
Influenza vaccination of healthcare workers does not have an impact on patients.

43. Modes of Transmission Droplets Airborne Contact
Thought to be primary mode of transmission
Coughing, sneezing, and talking
Heavy; settle within 6 feet of the source
Airborne
Related to procedures → aerosolized particles
Contact
Direct: skin-to-skin contact
Indirect: contact with virus in the environment 43

44. Respiratory Protection Debate
CDC (during influenza season)
Fit-tested N95 respirators for care of patients with 2009 H1N1
Prioritized usage if limited resources
Yet, Standard and Droplet Precautions for seasonal influenza?
Infection Control and Infectious Diseases Societies*
No evidence that 2009 H1N1 transmitted differently than seasonal influenza
Standard and Droplet Precautions for routine care
*Recommending organizations:
World Health Organization (WHO) • Infectious Disease Society of America
Healthcare Infection Control Practices • Society for Healthcare Epidemiology of America
Advisory Committee (HICPAC) • Association of Professionals in Infection Control

45. Surgical Mask vs. N95 Respirator Randomized Study
Characteristic
Surgical Mask
N=212
N95 Respirator
N=210 P
Vaccinated
68 (30.2%)
62 (28.1%)
Lab-confirmed*
RT-PCR
H1N1 serology
Serology without symptoms
50 (23.6%)
6 (2.8%)
17 (8.0%)
29/44 (65.9%)
48 (22.9%)
4 (1.8%)
25 (11.9%)
31/44 (70.5%)
0.86
0.75
0.18
Physician visits
13 (6.1%)
13 (6.2%)
0.98
Influenza-like illness,
Fever and cough
9 (4.2%)
2 (1.0)
0.06
Work-related absenteeism
42 (19.8%)
39 (18.6)
*RT-PCR or serology
JAMA 2009;302:

46. UW Medicine
Standard, Droplet, and Contact Precautions for routine care
Place mask on coughing patients
Separate sick from non-sick patients
Surgical mask, eye protection, gown, and gloves
N95 respirators for higher-risk aerosol-generating procedures
Intubation and extubation
Bronchoscopy
Open suctioning of airway
Cardiopulmonary resuscitation
Suspected or Confirmed Cases of Influenza

47. 43 y o woman from Eritrea with 3 week h/o non-productive cough, fever, and night sweats

48. Now What?
AFB smear neg x (3 sputum, 2 BAL)
Sputum AMTD neg

49. Which of the following is the BEST approach?
Remove from airborne isolation as a negative AMTD test rules out infectious TB
Begin 4 drug therapy and remove patient from airborne isolation due to multiple negative AFB smears
Begin 4 drug therapy and keep in airborne isolation
Obtain interferon-gamma releasing assay (IGRA) as a negative result would rule out TB

50. 44 y o Vietnamese man with 6 month h/o pain and swelling of left medial thigh associated with fevers and night sweats

51. Pulmonary Involvement in Extrapulmonary TB
• 72 patients with XPTB
36 lymph nodes
12 pleura
6 CNS
6 GI
• 57 had sputum collection
• Weight loss associated
with positive sputum cx
OR 4.3 ( )
49% had abnormal CXR
Chest 2008;134:589-94

52. Sputum AFB Smear Smear positive Smear negative, culture-positive TB
5,000-10,000 organisms per ml of sputum must be present
Smear negative, culture-positive TB
Responsible for roughly 17% of TB transmission in San Francisco and Vancouver
40-50% of pulmonary TB cases in King County are smear negative
Am Rev Respir Dis 1966;95:998
Lancet 1999;353;444, Thorax 2004;59:286

53. Patient Safety and Infection Control
UW Medicine Strategic Goals
Reduction in HAI
Expectation of hand hygiene with EVERY patient EVERY the time
WSHA elimination of HAI by 2012
Mandatory reporting of HAI
CLA-BSI, VAP, selected surgical site infections
MRSA legislation
Increased linkage of reimbursement to quality
CMS preventable “medical errors”